Early implementation of exercise after breast cancer surgery: insights and opportunity

Background and objective

The clinical trial “Early Implementation of Exercise to Facilitate Recovery After Breast Cancer Surgery” addresses a critical aspect of breast cancer treatment recovery—shoulder function. Breast cancer surgery, including partial or total mastectomy, often causes shoulder dysfunction, with an impact on physical function and quality of life of patients (1). In fact, surgery directly affects through alterations in muscle morphology and neuromuscular function (1,2). Similarly, the impact that sentinel lymph node surgery or axillary lymphadenectomy contributes to the postoperative functional outcome in terms of axillary web syndrome, functional limitations, alterations in sensitivity, pain that leads the patient to reduce her physical activity in the postoperative period, also in terms of rehabilitation exercises (3).

These alterations are based on the changes in the microenvironment that surgery and radiotherapy induce, reducing the activation of quiescent cells at the muscular level, which in turn determines the blocking of their transformation into myoblasts and myocytes, with consequent loss of muscle mass (4).

Various methods are employed in clinical practice to prevent shoulder dysfunction after surgery, including early physiotherapy, passive and active range-of-motion exercises, manual therapy, and structured rehabilitation programs (2). These interventions aim to reduce stiffness, maintain mobility, and minimize the risk of complications such as lymphedema and chronic pain. In this context, structured exercise programs initiated soon after surgery have been proposed as an effective strategy to enhance functional recovery (5).

This study aimed to evaluate the efficacy of an early exercise intervention, initiated one day post-surgery, on improving shoulder range of motion (ROM) and strength in patients undergoing breast cancer surgery (6). Added a brief overview of clinical methods used to prevent shoulder dysfunction to enhance logical flow.

Study design and participants

Conducted at the Breast Cancer Center in Seoul, South Korea, this parallel-group, two-arm randomized clinical trial enrolled 56 patients with early-stage breast cancer scheduled for mastectomy. Participants were randomized into two groups: the tailored resistance exercise group and the usual care group, each comprising 28 patients. The exercise intervention group received a tailored program of supervised and home-based exercises, while the usual care group was provided with an information booklet.

Interventions

The intervention commenced one day post-surgery, involving four supervised sessions aligned with surgeon visits and daily home exercises for one month. The tailored exercise programs were adjusted based on individual recovery status, focusing on stretching and strength exercises. The usual care group received general postoperative care information without personalized exercise training. Exstensive description of intervention was reported in Supp. 2 (6). An expert committee, consisting of two exercise specialists, two breast surgeons, and a physiatrist, established the main goals of a post-surgical exercise program for breast cancer patients: early recovery of shoulder ROM and strength, pain reduction, and prevention of physical function and fitness decline. Key muscles affected during surgery and recovery were identified, and stretching and strengthening exercises were developed to be safe and not delay wound healing (6). Exercises were categorized by joint movement (agonists, antagonists, and synergists) and classified into three intensity levels based on ROM and strength requirements rather than cardiopulmonary stress. The program includes 10 stretching and 16 strengthening exercises tailored to patients’ individual ROM and strength variations, which were deemed more significant than surgery type. Beyond improving shoulder function, the program also targets whole-body fitness, allowing patients to strengthen unaffected areas, such as the non-surgical arm, core, and lower body (6). A notable consideration in the intervention was addressing lymph node drainage management. Instead of the vague term “remove lymph node drainage”, the program incorporated measures to promote safe recovery by preventing complications related to lymphatic fluid buildup. These included gentle exercises designed to encourage lymphatic circulation, reduce swelling, and avoid risks of lymphedema. The emphasis was on balancing early mobilization with minimizing potential side effects associated with drainage issues (6).

Outcomes and measurements

Primary outcomes measured were shoulder ROM and strength at 1 and 6 months post-surgery. Secondary outcomes included physical activity, body composition, and quality of life assessed at 6 months. The results demonstrated significant improvements in the exercise group compared to the usual care group. At 1 month, 19 patients (67.9%) of the exercise group recovered shoulder strength fully versus 1 patient (3.6%) in the usual care group (P<0.001). At 6 months, 22 patients (78.6%) regained full ROM, and 24 patients (85.7%) regained strength in the exercise group, compared to 6 patients (21.4%) and 5 patients (17.9%), respectively, in the usual care group (P<0.001).

Results

The trial’s findings are compelling. The exercise group showed superior recovery in shoulder function, less muscle mass loss, and improved physical activity and quality of life. Compliance rates were high, with 100% adherence to supervised sessions and 97% to home exercises in the intervention group. The data support that early, tailored exercise interventions can significantly enhance recovery outcomes for breast cancer surgery patients. Among secondary outcomes, analysis of body mass composition was performed at 1 and 6 months. The exercise group showed superior recovery in shoulder function, less muscle mass loss, and improved physical activity and quality of life. Compliance rates were high, with 100% adherence to supervised sessions and 97% to home exercises in the intervention group. The data support that early, tailored exercise interventions can significantly enhance recovery outcomes for breast cancer surgery patients. All patients had a worsening at POD1 compared to baseline, but patients in the actively treated experimental arm showed an improvement in all outcomes, including body composition and nerve pain, as reported in the eSupp. 2 (5).

The pattern of muscle mass change from before surgery to 6 months after surgery showed significant differences between the two groups (Tab. 3; eTab. 3 in Supp. 2). Although both groups experienced a decrease in muscle mass, the usual care group exhibited a greater decline. This suggests that the tailored exercise program not only supports functional recovery but also plays a critical role in mitigating muscle mass loss during the postoperative period. These findings further emphasize the broader benefits of early physical rehabilitation in preserving body composition and overall physical health. Moreover, patients were also followed on SPADI Score item (Shoulder Pain and Disability Index) and results showed that patients who underwent usual care presented at 1 month after surgery worst outcomes in terms of pain and at 1 and 6 months after surgery in terms of disability (P<0.001).

Among surgical complications in terms of seroma and hematoma, no statistical differences were found between the two arms. One case of axillary web syndrome was reported in the usual care arm.

Discussion

Clinical results of this trial are very impactful. First of all, in exercise group, functional performance after treatment was 50 almost 19-fold time better than in respect no exercise group (67.9% vs. 3.6%). This recovery presents not only a benefit in terms of quality of life itself, but can also have an impact on management of further treatments. In fact, in a study of Marazzi et al., retrospective analysis on a breast cancer cohort of patients showed that ROM in abduction is directly related with radiotherapy mean dose to scapula humeral articulation (SHA), and consequently with quality of life in terms of Disability of the Arm, Shoulder and Hand (DASH) score points (7). Early recovery in ROM with exercise program, can help to preserve SHA also during radiotherapy treatments. In the study of Min et al., volumes of radiotherapy are not reported. It would be interesting to conduct a retrospective review of this cohort to analyze also the outcomes and relate them to mean dose delivered to SHA. Furthermore, a significant consideration is the potential preventative benefits of such exercise protocols regarding the side effects of radiotherapy on lymph nodes. Radiation therapy, while crucial in managing breast cancer, often leads to complications such as lymphedema—a condition characterized by swelling due to lymph fluid buildup, usually in the arms (1). Early and structured exercise regimens may help mitigate this risk by enhancing lymphatic drainage and reducing inflammation, thereby preventing the onset or progression of lymphedema. These programs do not impact the delay in starting radiotherapy, because radiotherapy must be started within 3 months of surgery and the exercises in the program could be continued during radiation treatment.

As the authors hypothesize in the discussion, there is certainly a collateral benefit in terms of reduction of subsequent health care expenditure. In many studies, economic costs are examined prospectively and the exercise program shows a reduction in costs compared to the standard approach (8). In a systematic review by Khan et al., evidence on the cost-effectiveness of exercise and physiotherapy interventions for the treatment of breast cancer was reported (9). In another recent study published in the Journal of Cancer Survivorship highlighted that breast cancer survivors experiencing arm morbidity are at a higher risk of financial hardship. Symptoms such as pain, swelling, and functional limitations of the upper limb are associated with increased medical expenses and reduced work capacity, exacerbating the financial burden on patients. Implementing early, targeted exercise programs to restore arm functionality could not only improve clinical outcomes but also help reduce postoperative complications. This approach is particularly beneficial for patients with limited financial resources, as it may prevent or mitigate the economic challenges associated with physical impairments after surgery (10).

This study’s outcomes are consistent with previous research emphasizing the benefits of physical rehabilitation in cancer care. For instance, prior publications on physical activity interventions for breast cancer patients highlighted the positive impact of exercise on reducing fatigue, lymphedema, improving mood, and enhancing overall quality of life (8,11,12). This reinforces the idea that early, structured exercise programs are not only feasible but highly beneficial for postoperative recovery (13).

A limitation of the study is lack of detailed information about exercise schedule and its validation. It would have been interesting to have more details about it, also in order to confirm results on real-world cohorts. Another limitation of the study is that, given the predominance of partial resections in this study, it is important to consider whether the intensity and timing of exercise initiation should be stratified according to the specific surgical techniques employed. Different procedures, such as lumpectomy, mastectomy, and axillary lymph node dissection, may influence postoperative pain, mobility restrictions, and recovery rates. Patients undergoing more extensive surgeries, such as total mastectomy or axillary lymph node dissection, may experience greater functional impairment and a higher risk of complications, necessitating a more gradual and closely monitored rehabilitation approach. Conversely, patients with partial resections may tolerate earlier and more intensive exercise interventions. Stratifying exercise protocols based on surgical extent and individual patient recovery trajectories could enhance clinical applicability and optimize patient outcomes. Future research should focus on personalized rehabilitation strategies that account for these variables to further refine postoperative exercise recommendations. We acknowledge that while the study by Min et al. provides valuable insights into the benefits of early exercise after breast cancer surgery, certain aspects of its design could be improved to enhance its applicability. Specifically, the sample size was relatively small, which may limit the generalizability of the findings to a broader patient population. Additionally, the study was conducted in a single-center setting, which may not fully capture the variability in clinical practices across different institutions. Future research should consider larger, multi-center trials with more diverse patient populations to improve the representativeness and external validity of the results.

Integrating digital tools and artificial intelligence (AI)-based platforms could further personalize and optimize rehabilitation programs, ensuring that patients receive the most effective interventions tailored to their unique needs and recovery trajectories. At the present time, some studies on AI applied to physical recovery have investigated post-stroke effect (14,15). Future research could explore the synergy between physical and digital therapies, potentially leading to even more robust recovery outcomes.

Conclusions and relevance

This study underscores the importance of integrating early exercise programs into postoperative care for breast cancer patients. The tailored exercise intervention, initiated immediately post-surgery, proved effective in improving shoulder function and overall quality of life. These findings advocate for a paradigm shift in postoperative care, emphasizing the role of structured physical rehabilitation in enhancing recovery and long-term outcomes for breast cancer survivors. The trial highlights a critical window for intervention and provides a robust model for similar future studies and clinical applications. Additionally, the potential to prevent radiotherapy-induced complications like lymphedema further underscores the value of early exercise interventions.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Clinical Trials Review. The article has undergone external peer review.

Peer Review File: Available at https://actr.amegroups.com/article/view/10.21037/actr-24-190/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://actr.amegroups.com/article/view/10.21037/actr-24-190/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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